WOMEN AND NEWBORN HEALTH SERVICE King Edward Memorial Hospital

DPMS Ref: 8489

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 1 of 5

Date Issued: June 2001 Depot Medroxyprogesterone Acetate (DMPA) Date Revised: October 2012 Obstetrics & Gynaecology Review Date: October 2015 Clinical Guidelines Authorised by: OGCCU King Edward Memorial Hospital Review Team: OGCCU Perth Western Australia

DEPOT MEDROXYPROGESTERONE ACETATE (DMPA) Note: Click on the individual subjects below; the hyperlink will then take you to that section in the document.

Background information

Key points

Efficacy

Contra-indications

Side effects

Medical history and examination

Dosage and administration

Initiation of DMPA

Counselling

Follow-up

BACKGROUND INFORMATION

Depot medroxyprogesterone acetate (DMPA) is a progestogen only method of contraception which is given by intramuscular injection. It is available in Australia as Depo-Provera® or Depo-Ralovera®. DMPA works by prevention of ovulation, causes cervical mucus thickening, and possibly interferes with implantation

1.

DMPA contraception may be a preferable option for women who cannot tolerate oestrogen, or who have a past history of ectopic pregnancy as the anovulant effect prevents pregnancy in any location. Women with a history of epilepsy using DMPA may have the frequency of seizures reduced, and for women with whom long term progesterone is indicated e.g. sickle cell disease it may be an option (causes an improvement of the haematological picture).

2 It can provide a suitable alternative method of

contraception for women who are unable to tolerate oral methods e.g. women with inflammatory bowel disease or malabsorption problems.

1

Evidence has shown that DMPA is associated with a reduction of bone mineral density, although this is mostly reversible after discontinuation of use. This is particularly relevant for adolescents who have not yet reached peak bone mass. Women more than 45 years of age should consider other forms of contraception as there are concerns regarding the hypo-oestrogenic effects of DMPA and the onset of menopause, however this is not a contraindication.

1 40% women will have a weight gain of up to 2 kg

during the first year of use.2

KEY POINTS

1. Pregnancy should be excluded prior to administration of DPMA contraception.1

2. DPMA injection can be given any time after 6 weeks postpartum.1

3. DPMA is given by deep intramuscular injection every 12 weeks ± 14 days. Repeat injections however can be given up to 16 weeks after the previous injection with little risk of pregnancy.

1

CONTRACEPTION

CLINICAL GUIDELINES

OBSTETRICS AND GYNAECOLOGY

Date Issued: June 2001 Depot Medroxyprogesterone Acetate (DMPA) Date Revised: October 2012 Obstetrics & Gynaecology Review Date: October 2015 Clinical Guidelines Written by:/Authorised by: OGCCU King Edward Memorial Hospital Review Team: OGCCU Perth Western Australia

DPMS Ref: 8489

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 2 of 5

4. DMPA users experience a mean reduction in bone mineral density of 7.7% and 6.4% in the hip and spine compared to 1.6% in controls over a 4 year period. DPMA users regain some bone mineral density after discontinuation. There is no evidence linking DPMA to increased risk of fractures.

1

5. The World Heath Organisation recommends women 18 - 45 years can use DPMA without restriction. Sexual Health and Family Planning Australia recommend alternative contraceptive methods should be considered first for women who are under 18 or over 45 years of age before prescribing DPMA.

1

6. Fertility may be delayed for up to 18 months following DPMA.1

EFFICACY

Perfect use 99.7% efficacy, and typical use results in 97% efficacy.1

CONTRAINDICATIONS

ABSOLUTE CONTRAINDICATIONS1

Breast cancer diagnosed within the last five years.

STRONG RELATIVE CONTRAINDICATIONS1

Cardiovascular disease including angina or myocardial infarction, peripheral vascular disease, transient ischaemic attack or stroke, hypertensive retinopathy, and multiple risk factors for cardiovascular disease.

Cerebrovascular accident.

Current deep vein thrombosis/pulmonary embolus, defined as currently being treated with an anticoagulant.

Migraine with aura occurring for the first time, or recurring with DPMA use.

Type 2 diabetes with vascular complications (including hypertension, nephropathy, retinopathy or neuropathy), or of greater than 20 years duration.

Past history of breast cancer with no current disease for 5 years.

Active viral liver disease, decompensated cirrhosis, benign or malignant liver tumours.

Unexplained abnormal vaginal bleeding.

Gestational trophoblastic neoplasia with abnormal ßhCG.

SIDE EFFECTS

Include1:

irregular bleeding

weight gain

delay in return to fertility

headaches

breast tenderness

acne

loss of bone density.

DPMS Ref: 8489

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 3 of 5

WOMEN AND NEWBORN HEALTH SERVICE King Edward Memorial Hospital

MEDICAL HISTORY AND EXAMINATION

Medical History

This includes:

Risk for osteoporosis – detailed assessment and advice should be completed for new users, and every year for continuing users.

1 Discuss risk of bone mineral density reduction which is

associated DPMA use.

Menstrual history – ensure the ‘last period’ was not an implantation bleed. Note: a negative pregnancy test does not exclude early pregnancy if the woman had unprotected sex in the previous 3 weeks.

1

Cardiovascular history – assess risk. Note: multiple risk factors increase risk for cardiovascular disease.

1

Thromboembolic disease – e.g. assess risk for thrombogenic mutation and family history1

Plan for future pregnancy – fertility may be delayed for up to 18 months.1

Depression – caution is warranted, however evidence for linkage is not strong.1

Examination

1. Perform a blood pressure.

2. Measure weight and calculate the BMI.

3. Screen for cervical cancer as required.

4. Check for sexually transmitted infections (STIs) as required.

DOSAGE AND ADMINISTRATION

Administer 150mg medroxyprogesterone acetate in a 1ml aqueous microcrystalline solution by deep

intramuscular injection into the gluteal or deltoid muscle every 12 weeks ±14 days.1

MANAGEMENT IF LATE FOR THE DMPA INJECTION1

A women can have a repeat injection after her menstrual period if 16 weeks has elapsed since the last DPMA injection provided: the woman has an negative pregnancy test is advised to use condoms for 7 days returns for a pregnancy test in 4 weeks time

A DPMA injection can be safely given if no intercourse has occurred during the 14 weeks since the last injection, but abstinence or condom use is advised for 7 days.

12-14 weeks since the last injection – DMPA can be safely given.

INITIATION OF DPMA1

SITUATION GIVEN EFFECTIVE

No contraception or barriers Day 1 of the first day of bleeding in normal menstrual cycle to day 5

At any other time; exclude pregnancy

Immediately

7 days

Combined pill or vaginal ring Anytime if the pills / vaginal ring have been taken/used correctly

Immediately

Date Issued: June 2001 Depot Medroxyprogesterone Acetate (DMPA) Date Revised: October 2012 Obstetrics & Gynaecology Review Date: October 2015 Clinical Guidelines Written by:/Authorised by: OGCCU King Edward Memorial Hospital Review Team: OGCCU Perth Western Australia

DPMS Ref: 8489

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 4 of 5

SITUATION GIVEN EFFECTIVE

DMPA injection Anytime if within 14 weeks of injection

Immediately

Etonogestrel Implant Anytime if within 3 years of insertion

7 days, or remove the implant 7 days after the injection

Progestogen only pill (POP) Anytime if the pills have been taken correctly otherwise pregnancy should be excluded

Effective within 7 days, or continue POP for an additional 7 days

Abortion Immediately Immediately

Copper or levonorgestrel IUD Day 1 of the first day of bleeding in normal menstrual cycle to day 5

Other times – condoms for 7 days prior to removal of IUD

Immediate

7 days, or leave the IUD in place for an additional 7 days

Post partum – fully breastfeeding

Less than 6 weeks postpartum (DPMA is category 2 which indicates it can be generally used before 6 weeks but follow-up is

required)

More than 6 weeks post partum and no menses-anytime if pregnancy is excluded

If the menstrual cycle has resumed – as above for no contraception or barriers

Immediately

7 days

As above

Post partum – not or not fully breastfeeding

Less than 21 days postpartum – anytime

More than 21 days postpartum and no menses – anytime if pregnancy is excluded

If the menstrual cycle has resumed – as above for no contraception or barriers

Immediate

7 days

As above

COUNSELLING

Discussion should include:

method and frequency of injections

risk factors and side-effects

follow-up with the GP or family planning services Provide the women with written information,

3 or where to access information about DPMA which is

available from Family Planning Western Australia at http://www.fpwa.org.au/

Date Issued: June 2001 Depot Medroxyprogesterone Acetate (DMPA) Date Revised: October 2012 Obstetrics & Gynaecology Review Date: October 2015 Clinical Guidelines Written by:/Authorised by: OGCCU King Edward Memorial Hospital Review Team: OGCCU Perth Western Australia

DPMS Ref: 8489

All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 5 of 5

FOLLOW-UP

Women should be reviewed following each DPMA injection for the following:

presence of side-effects1

new medical conditions1

new medications1

change in bleeding patterns1

assessment of risk for osteoporosis1

risk for STIs1

cervical and breast screening1

pregnancy planning1

signs or symptoms of infection at the injection site4

REFERENCES

1. Sexual Health & Family Planning Australia. Contraception: an Australian clinical practice handbook. 2nd ed. Canberra2008.

2. Guillebaud J. Your questions answered. Contraception. 4th edition ed: Churchill Livingstone; 2004.

3. Family Planning Association of Western Australia. Contraception Injection. 2011; Available from: http://www.fpwa.org.au/resources/Infosheet_Depo_web.pdf.

4. Faculty of Sexual and Reproductive Healthcare. Progesterone-only Injectable Contraception. 2009; Available from: http://www.fsrh.org/pdfs/CEUGuidanceProgestogenOnlyInjectables09.pdf.